In the piece below, published originally on the Primary Care for America blog, Elation's Co-founder and CEO, Kyna Fong, asks us to imagine a nation without primary care to open up a conversation about the important role that primary care clinicians play in the well-being and sustainability of the U.S. 

The U.S. healthcare system has a pernicious problem: As a society, we don’t understand the value of primary care. As a result, it is at risk of extinction.

Instead of primary care, we’ve been conditioned to value tests and procedures, hospitals, and highly subspecialized care. The work of primary care is cognitively demanding and relational, grounded in prevention and wellbeing through better self-management. Yet less than 5% of U.S. healthcare dollars are spent on primary care, despite 50% of office visits being to a primary care physician. As a result, we find ourselves in a culture which both glorifies and highly compensates procedural specialties and hospital-based care, but undervalues the kind of care that could prevent those things.

This chronic underinvestment is already impacting the number of primary care physicians available to treat patients today. Robbed of autonomy, shrunken in scope, and overwhelmed with bureaucracy and too many patients, primary care is burdened by physician burnout, unmet patient needs, and loss of trust. Recent estimates from the Association of American Medical Colleges predict a shortage of up to 40,400 primary care physicians by 2036 — a problem which quintuples if care were delivered equitably. In a report from the Robert Graham Center, 27% of adults and 10% of children in the U.S. — a whopping 79 million Americans — do not have an identified primary care physician, and the number of primary care physicians per capita has been declining over time.

If we don’t take active measures today, we risk losing this essential feature which helps hold together the delicate fabric of our society.

Primary care’s potential to transform healthcare 

High-functioning, high-value primary care in America is care that enables patients and families to have easy access to a doctor who knows them and spends time with them, who helps them sort through diagnostic dilemmas, promotes prevention and wellness, raises health literacy, and even helps avert catastrophe. Ideally, these primary care practices are supported by extended care teams that expand the concept of primary care, to include mental health, social work, musculoskeletal services, and other skill sets complementary to primary care.

Despite the current headwinds, there are many examples of this care today, proving that when supported by proper investment and with financial incentives aligned with patients’ best interests, primary care not only produces better health outcomes but also impressively decreases total healthcare spending by reducing the need for those expensive downstream services. This also dramatically improves the experience of care for both patients and their primary care teams.

Can we save primary care from extinction?

The only path to a better functioning U.S. healthcare system involves drastic interventions to rescue our foundation of primary care. The consequences of its loss would impact the health, wealth, and wellbeing of every American.

To save primary care from extinction, we must immediately take the following actions:

• Pay primary care prospectively to manage populations, instead of retrospectively for managing transactional encounters, at rates which both recognize the value they contribute to health outcomes and overall costs, and allow them to keep patient panel sizes manageable.
• Remove all but the clinically essential administrative burdens currently overwhelming primary care, including complex coding for billing and quality reporting, risk adjustment activities, and prior authorizations. Employ alternate ways to measure the quality of care and risk stratify populations; empower primary care to spend time reducing costs through clinical interventions rather than utilization management strategies.
• Provide technology which empowers, rather than obstructs, the clinical relationship between physician and patient and physician and collaborators. Give primary care tools to understand the health and cost risk of each patient and resource them to appropriately intervene to improve these outcomes.
• Create a bold student loan repayment program to eliminate debt for any graduating medical student who commits to spend at least 10 years actively practicing in a primary care specialty. Increase scholarship programs that promote a more diverse physician workforce, starting in medical school.
• Double the number of medical school slots and family medicine residency slots. Allow foreign medical graduates who commit to spend at least 10 years actively practicing in a primary care specialty to remain in the U.S. after residency.

What happens if primary care disappears?

If we imagine a nation without primary care, we can make a few sound predictions:

• Without primary care to coordinate and integrate care and organize the health system around the patient, healthcare will become increasingly fragmented, disorganized, and inefficient. This drives up duplicative and unnecessary services, contributing to avoidable spending and exposing patients to potential harm from complications related to unnecessary care.
• Without primary care to deliver services focused on prevention, early detection, and proactive management of diseases, we can expect increases in prevalence of late stage cancer, end stage renal disease, communicable diseases, cardiovascular deaths, and many other regrettable health consequences of an ineffective healthcare system focused on sick care delivered in silos and inequitably.
• Without primary care to serve as a healthcare partner, patients will lack the literacy to get their healthcare needs met, lost in a convoluted system with no one to advocate and interpret for them.
• Without primary care to close health equity gaps, unmet healthcare needs will be felt most intensely by vulnerable and marginalized populations, resulting in even more preventable tragedies and wider health equity gaps than we see today, with worsening infant mortality rates, maternal mortality rates, and life expectancy.
• Without primary care to influence up to 90% of total healthcare costs, national healthcare expenditures — currently increasing faster than gross domestic product and projected to top $4.8T for 2023 — will cripple the nation’s economy.

Without primary care to intervene in patients’ lives in big ways and small — treating headaches, flu, ankle sprains, depression, hypertension, arthritis, and many, many other conditions — there will never be enough emergency rooms and subspecialists to take care of the consequences. Healthcare spending and an unhealthy workforce will devastate the economy while life expectancy declines and society crumbles.

While it is hardly fathomable to envision a nation without primary care, there is credible risk of this outcome unless we prioritize it. By improving how we empower, pay, and support primary care, America will be a healthier, wealthier, and sustainable nation.